- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,922.45 / $2,922.45 / $2,922.45
| Professional | | $2,922.45 | $2,922.45 | $2,922.45 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,186.87 / $5,186.87 / $5,186.87
| Facility | | $5,186.87 | $5,186.87 | $5,186.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,728.42 / $3,728.42 / $7,182.12
| Professional | | $3,728.42 | $3,728.42 | $7,182.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,540.89 / $1,540.89 / $1,540.89
| Professional | | $1,540.89 | $1,540.89 | $1,540.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,570.43 / $6,529.20 / $9,140.87
| Professional | | $4,570.43 | $6,529.20 | $9,140.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,677.20 / $6,104.80 / $7,182.12
| Professional | | $3,677.20 | $6,104.80 | $7,182.12 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,259.51 / $5,439.76 / $6,214.59
| Professional | | $5,259.51 | $5,439.76 | $6,214.59 |